How to enroll

Steps to become a COBRA or PEBB continuation coverage subscriber.

How do I elect continuation coverage?

To choose PEBB Program continuation coverage, send either the completed COBRA Continuation Coverage or PEBB Continuation Coverage Election/Change form no later than 60 days after the date your employer-sponsored coverage ends or from the postmark on the PEBB Program Continuation Coverage Election Notice packet sent to you, whichever is later.

Oral communications (in person or by telephone) and electronic communications (fax or email) are not acceptable methods of election, and will not preserve your continuation coverage rights. If you do not submit completed form(s) by the deadline, your PEBB coverage will end on the last day of the month following the date of the qualifying event.

Important! If you, your dependents, or your representative does not notify your employer or the PEBB Program in writing no later than 60 days after the qualifying event date or the date eligibility ceases, whichever occurs later, you and your covered dependents will lose the right to elect COBRA or PEBB continuation coverage.

Who must provide notice when I lose eligibility for PEBB coverage?

Your employer must notify the PEBB Program if:

  • Your (the employee’s) employment ends.
  • Your (the employee’s) hours of employment are reduced.
  • You (the employee) die.
  • You (the retiree) lose eligibility for PEBB retiree insurance because your employer group ceases participation in PEBB health coverage. (Retirees of school districts and educational service districts can continue PEBB retiree coverage, even if their district discontinues participation or never participated with the PEBB Program).

You, your dependents, or a representative acting on your behalf must provide written notice to the PEBB Program if:

  • You divorce or terminate a registered domestic partnership.
  • Your child loses eligibility (loss of dependent status).
  • You lose eligibility for PEBB  retiree insurance because the Department of Retirement Systems (DRS) determines you are no longer disabled and stops your pension.

Your dependents or a representative acting on your behalf must provide written notice to the PEBB Program if:

  • You (the employee or retiree) die.

You, your dependents, or your representative must provide written notice to your employer’s personnel, payroll, or benefits office (if you’re an employee), or the PEBB Program (if you’re a retiree) no later than 60 days after whichever occurs later:

  1. The date of the qualifying event.
    or
  2. The date you or a covered dependent loses (or would lose) eligibility for PEBB coverage due to a qualifying event.

Example 1: If you divorce your spouse on June 15, the qualifying event date is June 15. Your former spouse loses eligibility for PEBB benefits on the last day of the month (June 30) in which the divorce occurred. The PEBB Program must receive written notice of the qualifying event no later than 60 days after the qualifying event date or the date eligibility ends, whichever occurs later. In this case, eligibility for PEBB coverage ends on June 30, after the qualifying event date (June 15). Therefore, your employer or the PEBB Program must receive written notice no later than 60 days after June 30.

Example 2: You cancel coverage for your spouse on December 31 in anticipation of a divorce, but your divorce is not final until June 15. The PEBB Program must receive written notice of the qualifying event no later than 60 days after the qualifying event date (June 15) or the date PEBB coverage ends (December 31). In this case, the qualifying event date occurs June 15, after PEBB coverage ends. Therefore, your employer or the PEBB Program must receive written notice no later than 60 days after June 15.

Once your employer or the PEBB Program is notified of the qualifying event, a PEBB Continuation Coverage Election Notice will be mailed to the address you provide.

What information is needed to provide notice of a qualifying event?

Any notice you, your dependent, or your representative provides must include:

  1. The name and address of the employee or retiree who is (or was) covered.
  2. The name, address, telephone number, and signature of the person providing the notice.
  3. The names and addresses of all qualified beneficiaries who lost coverage as a result of the qualifying event.
  4. The qualifying event and the date it happened.

If providing notice of a divorce or termination of state-registered domestic partnership: In addition to items 1-4 above, include proof of the divorce or termination of state-registered domestic partnership. If you notify the PEBB Program that your coverage was reduced or cancelled in anticipation of a divorce or termination of a state-registered domestic partnership, your notice must include proof that your coverage was reduced or cancelled.

How long does continuation coverage last?

COBRA coverage and PEBB continuation coverage provide temporary health plan coverage. Maximum coverage periods can last anywhere from 12 to 36 months and are based on the qualifying event that caused you or your covered dependent to lose PEBB health coverage. A table listing the maximum coverage periods based on the qualifying events is available the Initial Notice of COBRA and Continuation Coverage Rights.

Coverage can end before the maximum coverage period if:

  • Automatically canceled because premiums are not paid in full on time or the employer stops providing any group health plan for its employees.
  • Automatically canceled because you become entitled to Medicare or become covered under other group health coverage.
  • A qualified beneficiary stops being disabled.
  • You ask to cancel coverage.

For details consult the Continuation Coverage Election Notice booklet.

When can continuation coverage be extended?

If you or your qualified beneficiaries are enrolled in COBRA coverage or PEBB continuation coverage (leave without pay) for 18 months due to the employee’s termination of employment or reduction of hours, there are two ways in which this 18-month period of continuation coverage can be extended:

  1. When you or a qualified beneficiary is determined disabled by the Social Security Administration.
  2. When a second qualifying event occurs.

Disability extension of coverage

If the Social Security Administration determines that any qualified beneficiary is disabled, you and all of the qualified beneficiaries in your family may be entitled to receive up to 11 months of additional continuation coverage (for a total of 29 months). This extension is available only to those individuals who are receiving continuation coverage because of the covered employee’s termination of employment or reduction of hours.

The disability must have started before the 61st day after the covered employee’s termination of employment or reduction in hours, and must last at least until the end of the 18-month continuation coverage period.

The disability extension is available only if you notify the PEBB Program in writing and submit a COBRA Continuation Coverage or form and a copy of the disability award letter from the Social Security Administration no later than 60 days after the last of the following events:

  • The date of the Social Security Administration’s disability determination.
  • The date of the covered employee’s termination of employment or reduction of hours.
  • The date the qualified beneficiary loses (or would lose) coverage under PEBB rules as a result of the covered employee’s termination of employment or reduction of hours.
  • The date the PEBB Program mails a PEBB Continuation Coverage Election Notice to the qualified beneficiary, informing the beneficiary of his or her responsibility and the procedures to notify the PEBB Program.

You must also provide this notice within 18 months after the covered employee’s termination of employment or reduction of hours to be entitled to a disability extension. If the notice is not submitted to the PEBB Program during the 60-day notice period and within 18 months after the covered employee’s termination of employment or reduction of hours, then there will be no disability extension of COBRA or PEBB Continuation of Coverage.

Your notice must include:

  • The name and address of the employee or retiree who is (or was) covered.
  • The name, address, telephone number, and signature of the person providing the notice.
  • The names and addresses of all qualified beneficiaries who lost coverage as a result of the qualifying event.
  • The qualifying event and the date it happened.
  • The name and address of the disabled qualified beneficiary.
  • The date that the qualified beneficiary became disabled.
  • The names and addresses of all qualified beneficiaries who are receiving continuation coverage.
  • A copy of the Social Security Administration’s letter showing the disability determination date or a statement from the Social Security Administration that the qualified beneficiary is no longer disabled.

The right to the disability extension may be terminated if the Social Security Administration determines that the disabled qualified beneficiary is no longer disabled. You or your qualified beneficiaries have 30 days after the Social Security Administration’s determination to notify the PEBB Program when a qualified beneficiary is no longer disabled.

Second qualifying event extension of coverage

If your qualified beneficiary experiences a second qualifying event while receiving 18 months of continuation coverage (or 29 months, if the second event occurs during the disability extension), he or she may be entitled to receive up to an additional 18 months of continuation coverage, for a maximum of 36 months of continuation coverage.

To qualify for a second qualifying event extension of coverage, the second event must:

  • Occur during the initial continuation coverage period resulting from termination of employment, reduction of hours, or the retiree’s loss of PEBB Program retiree insurance due to termination of employer group participation with PEBB Program health coverage.
    and
  • Cause a qualified beneficiary to lose coverage under PEBB Program rules if the first qualifying event had not occurred. This includes:
    • The employee’s or retiree’s death.
    • Divorce.
    • Termination of a registered domestic partnership.
    • The dependent child loses eligibility for coverage under the PEBB Program rules.

Note: The second qualifying event extension is not available when an employee becomes entitled to Medicare after his or her termination of employment or reduction of hours.

Eligible dependents must have been covered under the plan on the day before the first qualifying event. Newborns or adopted children added after the first qualifying event are also eligible for the second qualifying event extension.

To request a second qualifying event extension, you or your qualified beneficiary must provide notice of the qualifying event to the PEBB Program in writing no later than 60 days after the later of:

  • The date of the second qualifying event.
  • The date the qualified beneficiary would lose coverage under PEBB Program rules as a result of the second qualifying event.
  • The date the PEBB Program provides the qualified beneficiary with a Summary Plan Document (also called a Certificate of Coverage or benefits booklet) either in print or online, informing the beneficiary of his or her responsibility and the procedures to notify the PEBB Program.
  • The date the PEBB Program mails a PEBB Continuation Coverage Election Notice to the qualified beneficiary, informing the beneficiary of his or her responsibility and the procedures to notify the PEBB Program.

Your notice must include:

  • The name and address of the employee or retiree who is (or was) covered.
  • The name, address, telephone number, and signature of the person providing the notice.
  • The names and addresses of all qualified beneficiaries who lost coverage as a result of the qualifying event.
  • The qualifying event and the date it happened.
  • The second qualifying event and the date it happened.
  • The names and addresses of all qualified beneficiaries who are receiving continuation coverage.
  • Proof of the second qualifying event.

What forms do I need?

COBRA

Continuation coverage (formerly Leave without pay)

More Forms